Hospital apology over tragic error

Whiston Hospital.
Whiston Hospital.
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A top doctor at Whiston Hospital issued an unreserved apology to the family of a St Helens grandmother at an inquest yesterday.

Dr Julia Hendry admitted that Nora Peters, 74, who was erroneously administered an oxygen-driven nebuliser in the days before she died, had been given “sub-optimal care”.

The inquest heard that the nebuliser should instead have been connected to a cylinder containing medical air.

Dr Hendry said: “I would like to apologise to Mrs Peters’ family on behalf of the trust. The care offered to Mrs Peters fell far short of the care our trust would normally offer to patients.”

An inquest at St Helens Town Hall heard how Mrs Peters, of Randon Grove, had been admitted to Whiston on May 15, 2013, suffering from breathlessness.

A long-time chronic obstructive pulmonary disease (COPD) sufferer, she had been an increasingly regular visitor to the hospital in the previous 12 months.

But doctors were working towards discharging her back home on May 20 when tragedy struck.

Staff nurse Tracy Stocks told how she noticed that the cylinder connected to Mrs Peters’ nebuliser was empty and how a healthcare assistant had then changed it on the evening of May 19.

But the wrong cylinder – one containing high-flow oxygen – was then used for “several minutes”.

The in-house Medical Emergency Team (MET) were then called to the ward shortly after 10pm and MET nurse Sarah Cordon noticed that the wrong cylinder had been used by staff.

Mrs Peters sadly passed away shortly before 10am on May 22.

An independent review conducted by Liverpool-based expert Dr Walshaw found that Mrs Peters died of “acute respiratory failure due to high-flow oxygen therapy due to end-stage COPD”.

A hospital spokeswoman said: “The trust offers its sincere condolences to the family of the late Mrs Peters, and has unreservedly apologised for the shortfalls in her care.

“An immediate and thorough investigation was carried out and staff have worked openly with the Coroner.

“The trust has introduced a number of additional measures to improve the quality of care including clearer labelling of gas cylinders and increased education of staff.”